Lingayen III Cluster

Data Entry (Athlete)

Athlete Record
Certificate of Enrollment
Certificate of Completion
Dental Certificate
 Republic of the Philippines
Department of Education
I
(Region)
SDO 1 PANGASINAN
(Division)
0
(School)
0
(School Address)

gayen III Cluster Eliminati

mination
Parental Consent
Medical Certificate (regular)
Medical Certificate 1
Medical Certificate 2
 I
Division: SDO 1 PANGASINAN
School Year: 2019-2020

Name:
Contact Number:
Sex:
Learner Reference Number (LRN)
Date of Birth: (mm/dd/yy)
Age:
Place of Birth:
School:
BEIS (Private School Number )
Address of School:
Home Address:
Parents:
Father's Name Mother's Name
Address of Parents:
Grade Level:
Section:
Event:
Coach:
Adviser/School Head/Registrar
School Head/Registrar
Guardian
Division Sports Officer ALBERTO L. MACARANAS JR.
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Mother's Name

R.
 AR-I (ATHLETE RECORD)
I
Region

SDO 1 PANGASINAN
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: 0
(Last) (First) (M.I.)
Sex: 0 Learner Reference Number (LRN) 0
Date of Birth: (mm/dd/yy) 12/30/99 Age: 0 Place of Birth: 0
School: 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks

(Use separate sheet if necessary)

Athlete's Signature
C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated
in the lower meets.
Athletic meet Name of Coach Signature Division Sports Officer

(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet

(Signature over Printed Name) (Signature over Printed Name)

Date: Date:
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 Republic of the Philippines
Department of Education
I
(Region)
SDO 1 PANGASINAN
(Division)
0
(School)
0
(School Address)

CERTIFICATE OF ENROLMENT

Date:

To Whom It May Concern:

This is to certify that 0 has been

enrolled in Grade 0 Section 0 for the School 2019-2020

0
Principal/School Head/Registrar
(Signature over printed name)
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 Republic of the Philippines
Department of Education
I
(Region)
SDO 1 PANGASINAN
(Division)
0
(School)
0
(School Address)

CERTIFICATE OF COMPLETION

To Whom It May Concern:

This is to certify that 0 has completed

the Grade 0 (Elementary/Secondary Level) for the School Year 2019-2020 .

0
Principal/School Head/Registrar
(Signature over printed name)
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 Republic of the Philippines
DEPARTMENT OF EDUCATION
I
Region
SDO 1 PANGASINAN
Division
Latest 1½ x 1½ picture
DENTAL HEALTH RECORD
Name: 0
Age: 0 Sex 0 Birth Date 12/30/99 Date
Event: 0
Parent/Guardian: 0
Coach: 0
CONDITION AND TREATMENT NEEDS GINGIVITIS
CONDITION PERIODONTAL
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT DISEASE
TEMPORARY TEETH MALOCCLUSION
SUPERNUMERARY
TOOTH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 RETAINED
PERMANENT TEETH
DECIDOUS TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CONDITION CLEFT PALATE
ROOT FRAGMENT
TREATMENT NEEDS
TEMPORARY TEETH FLUOROSIS
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT OTHERS (Specify)
CONDITION

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECAYED
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECAYED
OTHER ORAL TREATMENT NO. T/MISSING
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT

X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN
RF - ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP - ORAL PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH
Division Meet Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
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 Republic of the Philippines
Department of Education
I
(Region)
SDO 1 PANGASINAN
(Division)
0
(School)
0
(School Address)

P A R E N TA L C O N S E N T

Date:

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter 0 in the
Division, Regional Meet and Palarong Pambansa.
I have considered the benefits that my son or daughter will derive from his/her
participation in this activity provided that due care and precautio n will be observed to
ensure the comfort and safety of my son/daughter and that DepED employees and
personnel may not be held responsible for any untoward incident that may happen
beyond their control.

Signature of Father Signature of Mother

0 0
Name of Father Name of Mother

Signature of Guardian over Printed name

(Relationship with the Athlete)

Verified by :

0 0
Teacher-Adviser School Head/ Registrar

Remarks:
back to main
 Republic of the Philippines
Department of Education
I
(Region)
SDO 1 PANGASINAN
(Division)
0
(School)
0
(School Address)

M E D I CAL C E R T I FI CAT E

Date:

To Whom It May Concern:

This is to certify that I have personally examined 0

Name

age 0 sex 0 born on December 30, 1899 and have found that he/she is
physically fit, during the time of examination, to join and compete in the lower meets and
Palarong Pambansa.

Event: 0

Physical Examination

Date examined: _______________

Height Weight: Blood Pressure
Pulse, Resting Respiratory Rate
Other Remarks:

Physician/Medical Officer
(Signature over printed name)

License No.
PTR.:
Date:
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 Republic of the Philippines
Department of Education
I
(Region)
SDO 1 PANGASINAN
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
QUESTION FOR ATHLETE: IF YES, EXPLAIN MEDICA
PARENT L
OFFICER
1. Is a doctor currently treating you for anything? YES NO YES NO

2. Have you ever been unconscious or had a concussion?YES NO YES NO

3. Have you been hit hard in the head in the last 6 weeksYES NO YES NO

4. Have you had any headache in the last 2 weeks? YES NO YES NO

5. Do you have any problem in bleeding? YES NO YES NO

6. Does any disease run in your family ? Sudden unexpec YES NO YES NO

7. Have you had any surgery? YES NO YES NO

8. Have you ever had to stay in a hospital? YES NO YES NO

9. Do you have any medical condition? YES NO YES NO

0
Name and signature (Athlete) Name and signature (Parent)

Physician/Medical Officer
(Signature over printed name)
License No.
PTR.:
Date:
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 Republic of the Philippines
Department of Education
I
(Region)
SDO 1 PANGASINAN
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIE

S
Medical Examination following post
If Athlete had a Concussion in the
period after Concussion was Normal Abnormal
past year please certify that:
normal Athlete Fit to Box

List abnormalities not covered in

General Medical Exam
specific system exams below:

Mental Status/ Psychological Brief survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Head reactivity. Fundi, Vision by chart Normal Abnormal
(record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal
Neck Cervical spine, lymph nodes Normal Abnomal

Breath sounds, rib tenderness on

Chest Normal Abnormal
compression

Pulse/ blood pressure (record) Normal Abnormal

Cardio Vascular System

Heart examination: sounds,
Normal Abnormal
murmurs, heaves, size, rhythm

Upper limb: shoulder wrist, hand,

Orthopedic System Normal Abnormal
fingers

Lower limb: (ankle, knee, hip) Normal Abnormal

Relaxes Normal Abnormal

Neuclogical System Verbal reponses Normal Abnormal
Motor responses and balance Normal Abnormal
Asthma (record) Yes No
Allergies Type of reaction (record)
Medications used Name and dosage (record) Yes No

Fit to play Unfit to play

Name of MD________________________________________
Lic. Number:______________________
Date:______________________
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